2018-2019 Registration Form for New & Returning Students

Farmington School of Dance

Please make sure you have read about our classes and policies BEFORE you fill out your registration form! If you still have questions, please use our contact page to ask questions instead of this form. Thank you.

Please complete ONE form per child. Be sure to press
SUBMIT at the bottom of this page when you are finished.

*Indicates required response.

For Office Use Only

Dancer's Name (first & last) *

Parents' Names *

Custodial Care belongs to: *

Mom Only	Both Parents
Dad Only	Other Other

Street Address *

City *

State *

Zip Code *

Email Address *

Primary Contact Phone *

Work Phone

Home/Other phone

Age *

Birthdate (mm/dd/yyyy) *

Grade

School

Years of Dance *

List other studios you have attended.

If you have taken at another studio, please select all the forms of dance you have studied.

Emergency Contact Name *

Relationship *

Phone *

How did you find out about us? (Check all that apply.) *

Please use this space for additional questions, comments, special instructions or any allergies or medical conditions we should be made aware of.

In case of medical emergency, I understand that when medically feasible, an effort will be made to contact a parent/guardian, but in the event one is not reached or it is not medically feasible to contact one, I hereby give permission for my child to be treated. In the event consent is needed for medical care on a non-emergency basis and I cannot be reached, Sue Savage is authorized to act on my behalf. Furthermore, I agree to hold harmless Farmington School of Dance and all of their employees and agents in the event of an injury occurring to my child during any activities associated with the Farmington School of Dance. I recognize that participating in this activity has a certain amount of risk and that an injury is always possible. I certify that my child is, to the best of my knowledge, physically able to participate in this activity. I assume full financial responsibility for medical expenses arising out of such injury.

I also allow all pictures and film taken of my minor child to be used for publicity purposes for the Farmington School of Dance. I hereby indemnify and hold harmless against any and all claims of damages arising out of taking or use of pictures or videos of my minor child.

I agree that my child and I will abide by the standards set by this studio in the parent handbook. By signing this registration form, I assume full financial responsibility for registration, tuition, costumes, recital and all other fees.

Parents, enter your initials to show you agree to the above. Your physical signature may be required at a later date. *

Submitting this form indicates that you understand you are responsible for a $30 registration fee per dancer ($45 for family in the same household, paid for by the same person).

Payment method *

Cash at the studio

Check at the studio

Mail a check/money order

If you are mailing a check or money order, please sed to Farmington School of Dance 18 S. Jackson St., Farmington, MO 63640. We do have a payment box outside the studio if you would prefer to drop it in that. Please note student's name on the memo line of the check!

Scroll down to the bottom of the page to submit this form.
All fields marked with * must be completed in order to submit.

By clicking submit, you are financially obligated to sending in the registration fee.

If you are only looking for prices or schedule,

please return to our website.

All dancers registered through this form will be placed in a class and you will be billed for the registration fee.

Please call or email with additional questions or to request a paper registration form.

756-1856
info@farmingtonschoolofdance.com
Or return to our website for additional information.

Visitor since 8/12/2008

Ballet (Strict training)	Tap	Pointe	Lyrical
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Gymnastics/Tumbling	Poms

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